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Smoking cessation in hospital patients given repeated advice plus nicotine or placebo chewing gum
Respiratory Medicine (1991) 85, 155-157
Smoking cessation in hospital patients given repeated advice plus nicotine or placebo chewing gum I. A. CAMPBELL*'~, R. J. PRESCOTT~ AND S. M. TJEDER-BURTON'I"
tChest Unit, Llandough Hospital, Cardiff CF6 1XX and ~Medical Statistics Unit, University of Edinburgh, Edinburgh EH8 9AG, U.K.
Introduction
Hospital patients with smoking-related diseases rarely heed medical advice to stop smoking even when this advice is reinforced with nicotine gum and written material (1,2), the exception being those with acute myocardial infarction (3,4). In contrast, success rates with advice, nicotine gum and specialized support sessions in smoking cessation clinics range from 38% in healthy clients (5) to 29% in a mixed group of clients and patients (6). In our study the 'stop smoking' advice of the physician was reinforced by advice/support from a research assistant (SB) and by nicotine (N) or placebo (P) chewing gum.
Patients and Methods
Hospital inpatients with smoking-related diseases were advised by their physicians to give up smoking and were later seen by SB and invited to take part in the study. Before they left hospital, those who had agreed were given packages of identical appearance randomly containing either nicotine (2 mg) or placebo gum. SB instructed the patients on the use of the gum and reinforced the stop smoking advice. The patients were asked to attend outpatients to see SB at 2, 3 and 5 weeks, and 3 and 6 months when further advice and encouragement were given and gum supplies renewed. Stronger gum (4 mg N or P) was offered up to 3 months to those still smoking. Final review took place at 12 months. Claims of abstinence were verified by expired air CO. Success was defined as verified non-smoking at 6 and 12 months with claimed non-smoking between these times. Non-attenders were classified as failures. Received 12 July 1990and accepted8 November 1990. *To whom correspondenceshould be addressed. 0954-6111/91/020155 + 03 $03,00/0
PATIENTSNOTELIGIBLE Patients with organic psychosis, malignant disease, preterminal or terminal disease, drug and alcohol abuse and patients aged under 18 years were not eligible for the study.
Results
Two-hundred-and-nineteen patients (122 male) were recruited but seven pat!ents were not evaluable because of emigration, death or development of terminal cancer. The N and P groups were evenly balanced with respect to age, sex, number of cigarettes smoked daily, Fagerstrom score (a measure of nicotine dependence) and distribution of diagnoses (categories: heart disease, lung disease, peripheral vascular disease, peptic ulcer). The success rate was 20% in both the N and P groups. The only variables to have a statistically significant effect on success were the diagnosis and smoking level (Table 1): patients with heart disease did better than those with lung or other diseases, (success rates of 32% versus 1 3 0 versus 6% respectively, P = 0.002). Smokers of 16-25 cigarettes daily had better cessation rates than lighter or heavier smokers ( P = 0.003). Older patients tended to do better than younger ones (P = 0-06). There was no difference in success rates between the sexes, nor between the low-dependence and high-dependence groups as measured by the Fagerstrom score. The verification tests suggested that around 10% falsely claimed non-smoking status. Fifteen patients reported never using the gum. At 2 weeks, 61% were still using gum (median use: 6 pieces daily; interquartile range: 3-8). Median duration of gum use was 37 days (interquartile range 9-84 days). Fifty-three patients accepted the offer of higher strength gum (N, 29; P, 24): only one of these patients was ultimately a success. Unwanted effects were mild: 8% reported oral and 3% gastrointestinal problems in © 1991 Bailli6reTindall
156
L ,4. Campbell et al.
Table I
Nicotine gum versus placebo gum: patient characteristics and results Number of successes/number of patients
Age
Sex Diagnosis Cigarette smokers Fagerstrom score Treatment
<40 40--49 50-59 > 60 Male Female Lung disease Heart disease Other 1-I 5 16-25 >25 Low dependence (0-6) High dependence (7-1 I) Placebo gum Nicotine gum
Nictotine gum
Placebo gum
3/18 3/30 8/26 7/33 11/55 10/52 6/56 15/44 0/7 3/35 15[40 3/32 13/58 8/49 ---
4/27 3/24 7/21 7/33 13/64 8/41 8/55 12/41 I/9 5/39 8/30 8/28 9/52 12/53 ---
the nicotine group, compared to 6% and 7% respectively with placebo. There were no statistically significant differences between N and P with respect to any feature of gum use. Of 848 potential patient contacts prior to the 6 month assessment, 32% were made at outpatient attendances, 25% by telephone, 2% by home visits, 3% as inpatients and 39% were not achieved despite many attempts.
Discussion In this study repeated advice and support from SB were given after strong medical advice to stop smoking. SB is a medical secretary with good knowledge of smoking cessation and its difficulties but with no other specialized training. Nicotine gum was thus tested against placebo in a supportive setting which might be affordable by the National Health Service. Patients hospitalized for an acute illness may be more motivated to stop smoking than outpatients. This, and the greater proportion with cardiac problems among our patients, may explain, partly or entirely, why the success rate (20 %) was double that achieved in previous trials in hospital and chest clinic patients (1,2). However, patients were only motivated enough to keep one-third of their appointments with SB in the first 3 months. A trend for increasing age to predict success is in line with the results of the British Thoracic Society (BTS) studies (2,7). Those studies found that male patients
All patients 7/45 6/54 15/47 14/66 24/119 18/93 14/111 27/85 I / 16 8/74 23/70 11/60 22/110 20/102 21/105 21/I07
(16%) (I 1%) (32%) (21%) (20%) (19%) (13%) (32%) (6%) (11%) (33%) (18%) (20%) (20%) (20%) (20%)
Level of significance
;(2=7"5 P=0.06 Z2=0'0 P= 1.0 ;(2=13'I P= 0.002 Z-"= 11"8 P=0"003 ;(2=0'0 P= 1.0 ;(2=0"0 P= 1"0
were more successful than females at smoking cessation but in our study gender made no difference to success rate. We also noted a relationship between the number of cigarettes smoked daily and success whereas in the BTS studies no such effect was found. It is~possible that these differences between the results might have arisen because of the involvement of SB in the strategy but why this should have been so is not clear. Although the first BTS study (1) did not show an effect, a study of patients attending their general practitioners has suggested that chewing gum might add to advice (8). In our study the relative contribution of chewing gum, patient selection and repeated reinforcement of the physician's advice by a medical secretary to the improved success rate cannot be identified. But, in this difficult group, patients with smoking-related diseases, no difference emerged between N and P gums.
Acknowledgement We thank Pharmacia LEO.
References 1. British Thoracic Society. Comparison of four methods of smoking withdrawal in patients with smoking related diseases. Br MedJ 1983; 286: 595-597. 2. British Thoracic Society. Smoking cessation in patients: Two further studies by the BTS: (a) Health Visitors, postal encouragement and a signed agreement added to
Smoking cessation in hospital patients physician's advice; (b) postal encouragement and/or signed agreement as supplements to physician's advice. Thorax 1990;45: 835-840. 3. Burr A, Thornley P, Illingworth D, White P, Shaw TR, Turner R. Stopping smoking after myocardial infarction. Lancet 1974; I: 304-306. 4. Taylor CB, Houston-Miller N, Killen JD, DeBusk RF. Smoking cessation after acute myocardial infarction: effects of a nurse-managed intervention. Ann Intern Med I990; 113:118-123. 5. Jarvis MJ, Raw M, Russell MAH, Feyerabend C.
157
Randomised controlled trial of nicotine chewing gum. Br MedJ 1982; 285: 537-540. 6. Hjalmarson AIM. Effect of nicotine chewing gum in smoking cessation. A randomized placebo controlled double blind study. JAMA 1984;252: 2835-2838. 7. British Thoracic Society. Smoking withdrawal in hospital patients: factors associated with outcome. Thorax 1984; 39:651--656. 8. Campbell IA, Lyons E, Prescott RJ. Stopping smoking: do nicotine chewing gum and postal encouragement add to doctors' advice? The Practitioner 1987;2,31: 144-147.
Smoking cessation in hospital patients given repeated advice plus nicotine or placebo chewing gum I. A. CAMPBELL*'~, R. J. PRESCOTT~ AND S. M. TJEDER-BURTON'I"
tChest Unit, Llandough Hospital, Cardiff CF6 1XX and ~Medical Statistics Unit, University of Edinburgh, Edinburgh EH8 9AG, U.K.
Introduction
Hospital patients with smoking-related diseases rarely heed medical advice to stop smoking even when this advice is reinforced with nicotine gum and written material (1,2), the exception being those with acute myocardial infarction (3,4). In contrast, success rates with advice, nicotine gum and specialized support sessions in smoking cessation clinics range from 38% in healthy clients (5) to 29% in a mixed group of clients and patients (6). In our study the 'stop smoking' advice of the physician was reinforced by advice/support from a research assistant (SB) and by nicotine (N) or placebo (P) chewing gum.
Patients and Methods
Hospital inpatients with smoking-related diseases were advised by their physicians to give up smoking and were later seen by SB and invited to take part in the study. Before they left hospital, those who had agreed were given packages of identical appearance randomly containing either nicotine (2 mg) or placebo gum. SB instructed the patients on the use of the gum and reinforced the stop smoking advice. The patients were asked to attend outpatients to see SB at 2, 3 and 5 weeks, and 3 and 6 months when further advice and encouragement were given and gum supplies renewed. Stronger gum (4 mg N or P) was offered up to 3 months to those still smoking. Final review took place at 12 months. Claims of abstinence were verified by expired air CO. Success was defined as verified non-smoking at 6 and 12 months with claimed non-smoking between these times. Non-attenders were classified as failures. Received 12 July 1990and accepted8 November 1990. *To whom correspondenceshould be addressed. 0954-6111/91/020155 + 03 $03,00/0
PATIENTSNOTELIGIBLE Patients with organic psychosis, malignant disease, preterminal or terminal disease, drug and alcohol abuse and patients aged under 18 years were not eligible for the study.
Results
Two-hundred-and-nineteen patients (122 male) were recruited but seven pat!ents were not evaluable because of emigration, death or development of terminal cancer. The N and P groups were evenly balanced with respect to age, sex, number of cigarettes smoked daily, Fagerstrom score (a measure of nicotine dependence) and distribution of diagnoses (categories: heart disease, lung disease, peripheral vascular disease, peptic ulcer). The success rate was 20% in both the N and P groups. The only variables to have a statistically significant effect on success were the diagnosis and smoking level (Table 1): patients with heart disease did better than those with lung or other diseases, (success rates of 32% versus 1 3 0 versus 6% respectively, P = 0.002). Smokers of 16-25 cigarettes daily had better cessation rates than lighter or heavier smokers ( P = 0.003). Older patients tended to do better than younger ones (P = 0-06). There was no difference in success rates between the sexes, nor between the low-dependence and high-dependence groups as measured by the Fagerstrom score. The verification tests suggested that around 10% falsely claimed non-smoking status. Fifteen patients reported never using the gum. At 2 weeks, 61% were still using gum (median use: 6 pieces daily; interquartile range: 3-8). Median duration of gum use was 37 days (interquartile range 9-84 days). Fifty-three patients accepted the offer of higher strength gum (N, 29; P, 24): only one of these patients was ultimately a success. Unwanted effects were mild: 8% reported oral and 3% gastrointestinal problems in © 1991 Bailli6reTindall
156
L ,4. Campbell et al.
Table I
Nicotine gum versus placebo gum: patient characteristics and results Number of successes/number of patients
Age
Sex Diagnosis Cigarette smokers Fagerstrom score Treatment
<40 40--49 50-59 > 60 Male Female Lung disease Heart disease Other 1-I 5 16-25 >25 Low dependence (0-6) High dependence (7-1 I) Placebo gum Nicotine gum
Nictotine gum
Placebo gum
3/18 3/30 8/26 7/33 11/55 10/52 6/56 15/44 0/7 3/35 15[40 3/32 13/58 8/49 ---
4/27 3/24 7/21 7/33 13/64 8/41 8/55 12/41 I/9 5/39 8/30 8/28 9/52 12/53 ---
the nicotine group, compared to 6% and 7% respectively with placebo. There were no statistically significant differences between N and P with respect to any feature of gum use. Of 848 potential patient contacts prior to the 6 month assessment, 32% were made at outpatient attendances, 25% by telephone, 2% by home visits, 3% as inpatients and 39% were not achieved despite many attempts.
Discussion In this study repeated advice and support from SB were given after strong medical advice to stop smoking. SB is a medical secretary with good knowledge of smoking cessation and its difficulties but with no other specialized training. Nicotine gum was thus tested against placebo in a supportive setting which might be affordable by the National Health Service. Patients hospitalized for an acute illness may be more motivated to stop smoking than outpatients. This, and the greater proportion with cardiac problems among our patients, may explain, partly or entirely, why the success rate (20 %) was double that achieved in previous trials in hospital and chest clinic patients (1,2). However, patients were only motivated enough to keep one-third of their appointments with SB in the first 3 months. A trend for increasing age to predict success is in line with the results of the British Thoracic Society (BTS) studies (2,7). Those studies found that male patients
All patients 7/45 6/54 15/47 14/66 24/119 18/93 14/111 27/85 I / 16 8/74 23/70 11/60 22/110 20/102 21/105 21/I07
(16%) (I 1%) (32%) (21%) (20%) (19%) (13%) (32%) (6%) (11%) (33%) (18%) (20%) (20%) (20%) (20%)
Level of significance
;(2=7"5 P=0.06 Z2=0'0 P= 1.0 ;(2=13'I P= 0.002 Z-"= 11"8 P=0"003 ;(2=0'0 P= 1.0 ;(2=0"0 P= 1"0
were more successful than females at smoking cessation but in our study gender made no difference to success rate. We also noted a relationship between the number of cigarettes smoked daily and success whereas in the BTS studies no such effect was found. It is~possible that these differences between the results might have arisen because of the involvement of SB in the strategy but why this should have been so is not clear. Although the first BTS study (1) did not show an effect, a study of patients attending their general practitioners has suggested that chewing gum might add to advice (8). In our study the relative contribution of chewing gum, patient selection and repeated reinforcement of the physician's advice by a medical secretary to the improved success rate cannot be identified. But, in this difficult group, patients with smoking-related diseases, no difference emerged between N and P gums.
Acknowledgement We thank Pharmacia LEO.
References 1. British Thoracic Society. Comparison of four methods of smoking withdrawal in patients with smoking related diseases. Br MedJ 1983; 286: 595-597. 2. British Thoracic Society. Smoking cessation in patients: Two further studies by the BTS: (a) Health Visitors, postal encouragement and a signed agreement added to
Smoking cessation in hospital patients physician's advice; (b) postal encouragement and/or signed agreement as supplements to physician's advice. Thorax 1990;45: 835-840. 3. Burr A, Thornley P, Illingworth D, White P, Shaw TR, Turner R. Stopping smoking after myocardial infarction. Lancet 1974; I: 304-306. 4. Taylor CB, Houston-Miller N, Killen JD, DeBusk RF. Smoking cessation after acute myocardial infarction: effects of a nurse-managed intervention. Ann Intern Med I990; 113:118-123. 5. Jarvis MJ, Raw M, Russell MAH, Feyerabend C.
157
Randomised controlled trial of nicotine chewing gum. Br MedJ 1982; 285: 537-540. 6. Hjalmarson AIM. Effect of nicotine chewing gum in smoking cessation. A randomized placebo controlled double blind study. JAMA 1984;252: 2835-2838. 7. British Thoracic Society. Smoking withdrawal in hospital patients: factors associated with outcome. Thorax 1984; 39:651--656. 8. Campbell IA, Lyons E, Prescott RJ. Stopping smoking: do nicotine chewing gum and postal encouragement add to doctors' advice? The Practitioner 1987;2,31: 144-147.